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INSR ADDLSUBRLTRINSR WVD <br />DATE (MM/DD/YYYY) <br />PRODUCER CONTACTNAME: <br />FAXPHONE(A/C, No):(A/C, No, Ext): <br />E-MAILADDRESS: <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) <br />COMMERCIAL GENERAL LIABILITY <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />AUTHORIZED REPRESENTATIVE <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />Y / N <br />N / A <br />(Mandatory in NH) <br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? <br />EACH OCCURRENCE $ <br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR <br />MED EXP (Any one person) $ <br />PERSONAL & ADV INJURY $ <br />GENERAL AGGREGATE $ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP/OP AGG $ <br />$ <br />PRO- <br />OTHER: <br />LOCJECT <br />COMBINED SINGLE LIMIT $(Ea accident) <br />BODILY INJURY (Per person) $ANY AUTO <br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS <br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident) <br />$ <br />OCCUR EACH OCCURRENCE $ <br />CLAIMS-MADE AGGREGATE $ <br />DED RETENTION $ <br />$ <br />PER OTH-STATUTE ER <br />E.L. EACH ACCIDENT $ <br />E.L. DISEASE - EA EMPLOYEE $ <br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below <br />POLICY <br />NON-OWNED <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />CERTIFICATE HOLDER CANCELLATION <br />© 1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) <br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE <br />Twin City Fire Insurance Company <br />NAS Insurance <br />01/14/2019 <br />USI Insurance Services, LLC. Sm CL <br />6100 Fairview Road Suite 800 <br />Charlotte, NC 28210 <br />855-874-1396 <br />MidSouthSelectu@usi.com <br />XenTegra, LLC <br />9445 St. Barts Lane <br />Huntersville, NC 28078 <br />29459 <br />NONE <br />B Professional Liab <br />Cyber Liability <br />1112978 11/22/2018 11/22/2019 $2,000,000 <br />Orange County Local Government <br />North Carolinda <br />200 S Cameron St. <br />Hillsborough, NC 27278-2505 <br />1 of 1#S24757415/M24678495 <br />XENTEGTAClient#: 1489624 <br />LJME41 of 1#S24757415/M24678495 <br />DocuSign Envelope ID: 58960D58-D971-4D0C-8FD6-8630170E1088DocuSign Envelope ID: 4513128A-161B-4974-8BA0-1849A799EBA6DocuSign Envelope ID: 5685DE0F-7C00-484C-9731-394CB721E960